Worker's Compensation Fraud Allegation

Worker's Compensation Fraud Allegation

* NOTE: Providing your name, phone number and email address are optional, but very helpful. You may remain
anonymous by not completing those items.

* Your name, phone and email:

Name:

Phone Number:

Email:

Please provide any known information on the alleged fraudulent case below:

To be sure that we are able to adequately investigate your allegation, be sure to include as much of the following
information as possible. If you do not know the answer, don't worry; just tell us what you do know. Due to confidentiality requirements, we will not be able to provide you with any information regarding our investigation into the fraud allegation.

Fraud Allegation Information:

** Who is committing fraud?:

What is their full address:

Their Phone Number:

** What are they doing? (describe the alleged fraudulent activity):

** NOTE: Who is committing fraud? and What are they doing? : fields are required.